Analysis and Application: Understanding PTSD and Crisis Intervention

PTSD Nation
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 By Elizabeth Hall

Cassandra’s Case
Client: Cassandra Smith            DOB: 8/15/1985     Client CIS ID# CIT10854
Address: 3543 Sunnyvale Lane                            Client SSN: 409-65-8930
City: Lexington   State: KY   Zip: 40517   Phone (859) 849-5298
Case Type: Legal Services: Brought in by Lexington Police for Assessment of threat level to self or others.
            Initial Patient Screening Date: 11/22/2011
           Extra Background Information: Officers inform staff upon arrival that Cassandra is being detained for a fight with her boyfriend but that there are indications that she may have killed him, which is presently unconfirmed.
            Medical History:  Cassandra has been in therapy before as a child.  She has also attempted suicide on three occasions, with the last unsuccessful attempt happening three months ago with wrist cutting.
            Family Background:  There is a history of physical violence, sexual abuse, and substance abuse.  Client indicates that she was not born in the U.S., and while she lived in Argentina she witnessed he father and grandfather, sexually and physically abusing her mother, and suspects that the same happened to her as well.  She indicates that her father was an alcoholic and that her brother is a heroin addict.  There is no other history of mental illness in the family history.
Date: 11/22/2011
           Current Issues: This morning Lexington Police brought Cassandra in.  Upon speaking with her, I found her anxious, fidgety, continually asking if she can see her boyfriend, if she can see him, and if she is going to jail.  Upon talking with Ms Smith, I learn that she denies any ideations of suicide, but has definite homicidal ideations.  These fixate upon an undecided family member, stating that she often thought about what it would feel like to kill someone, and that she would, rather it be a family member or someone she knows because of the things they had “put her through”. When talking with her, she often smiles when talking about negative information, and seems unable to answer questions directly.  She also has nightmares in which she is in a fetal position sweating when thinking about her father.  The interview was short, as Ms. Smith became agitated and verbally abusive to officers when they disclosed that she was not free to leave.  Officers were present for the duration of the interview, as they felt that they should, because Ms. Smith was in custody.
            Recommendations: I recommend immediate hospitalization, for 72 hours for observation.  Because she is in police custody, I would recommend guards at the door instead of inside the room for confidentiality reasons.
        Figure 1

In response to the discovery of horrible practices and conditions found in the mental institutions of the past, congress passed the Community Mental Health Centers Construction Act in 1963 and the trend towards mental health care turned from institutionalization to deinstitutionalization, thereby releasing many who, would have once been put in a mental facility to society.  This stance continues today, however the number of mentally ill that are in our population numbers approximately 9.8 million people, and that the occurrence of serious mental illness in our country as of 2008 were highest in adults (over 18) aged from 18-25, and lowest in those older than 50 according to SAMHSA (2009).  James (2008), notes, that Post Traumatic Stress Disorder (PTSD) is one of the most common disorders that our crisis workers come across regularly.  In fact, other disorders, that the crisis worker may see that are evident during a crisis, could be directly caused by PTSD such as substance abuse, suicidal ideations, and anger management issues.
 In fact, the reality is that there is some proven correlation between substance abuse and PTSD. In this paper, we will examine one case where crisis intervention is utilized, in which the client, Cassandra, is displaying signs of Chronic PTSD, that she has been suffering with since she was a child.  Through her struggle, we can come to understand this disorder, and the steps a crisis worker must take to ensure a positive outcome to a potentially deadly crisis.  We will explore the ramifications of trauma, what it can do to the human psyche, and how to bring someone back from the edge of trauma related mental disorders.
Barlow & Durand (2007) define PTSD as a long lasting distressful emotional disorder that is triggered by a harsh threat that produces feelings of helplessness, and extreme fear.  During the course of the disorder, which is very disruptive, the client relives the trauma, avoids situations that remind them of the trauma, and become somewhat numb in their responsiveness to the world around them.  They also experience hyper vigilance, and extreme states of arousal, are easily irritated or angered, may have no conscious memory of the event or certain aspects of it, and may have hallucinations, or recurring nightmares.  The most common form of PTSD can be found in soldiers with heavy combat experience, although it can also be found in those who have been physically or sexually abused, victims of car accidents, natural disasters, and after the death of a loved one (Barlow & Durand, 2007).  
The National Center for PTSD (2010), states that the DSM-IV-TR has very specific criterion for the diagnosis of the disorder.  A client must exhibit both Criterion A Stressors.  This means, that they must have both, been witness or part of an incident which included actual threat of loss of life, injury, or physical integrity of one’s self or others, and the client’s reaction must have included “intense fear, helplessness, or horror”, the National Center for PTSD (2010), goes on to say.  Our client, Cassandra qualifies on this factor, due to the physical and/or sexual abuse possibly both witnessed and experienced, when she lived with her father.  They must now also fit several other criteria, before a diagnosis can be made. 
The next consideration is the Criterion B Stressors, which states that the incident must cause intrusive recollections holds the National Center for PTSD (2010).  The client must be experiencing recurrent thoughts, perceptions, dreams, hallucinations, or flashbacks, that are distressing,  Another thing to consider is that if the trauma occurred in a child, the effects are slightly different, as they tend to reenact scenes during play, and their nightmares may be just frightening, without meaning (National Center for PTSD, 2010).  Cassandra also fits this criterion, with her recurrent nightmares about her father.  Since her trauma occurred when she was a child, her non-specific dreams about her father.
Criterion group C must have three or more of the following qualifiers; avoidance of thoughts associated with the trauma, people, activities or places associated with the trauma, the incapacity to remember important parts of the trauma, no interest in major activities, feelings of a short future, and flattened emotional responses to others, emotions, and feelings (National Center for PTSD, 2010).  We can see this in Cassandra, as she is smiling when talking about negative aspects and information, also because she cannot seem to answer questions directly.  The Criterion group D is concerned with hyper arousal, and clients must display two areas of this measure to qualify as having PTSD.  These symptoms include trouble getting to, or staying asleep, irritability, and frequent outburst of anger, trouble concentrating, and hyper vigilance or elevated response to startling stimuli as noted by the National Center for PTSD (2010).  Cassandra clearly shows signs of these symptoms with the way she responded to the fact that she was not free to leave, and to the officers.
The last two Criterion Groups, E, and F, notes the National Center for PTSD 2010), specifically deal with the duration of the symptoms, and the level of dysfunction that the client is experiencing that is causing disruption in their lives.  The symptoms must have duration of at least one month for all previous criterions. They must also cause significant duress in the client’s professional or home life, but can also be causing stress in both.  In acute PTSD, the symptoms have been less than three months, whereas in Chronic PTSD they last for more than three months. 
In Cassandra’s case, she has been in psychiatric care as a child, and received some when she attempted suicide, which ties back to the trauma stemming from childhood, which would make this Chronic PTSD presenting in a transcrisis state when she attempts suicide, or in this case, where we find her in the custody of police.  Transcrisis states, according to James (2008), refer to the “emotional roller coaster” that is prevalent in trauma victims lives when they do not effectively deal with the crisis immediately following the incident, in terms of psychological acceptance.  This unprocessed trauma results in additional life stressors triggering emotional responses that revert directly back to the trauma, keeping the clients in a cycle of repeated problems until the issues are addressed (James, 2008).
Relation of Substance Abuse and PTSD
The National Center for PTSD (2009) relates that there is a direct correlation to substance abuse and PTSD.  They report that there are particularly high co morbidity rates between all mental illness and substance abuse, but it is commonly found in clients with PTSD.  James (2008) also notes that co morbidity is one of the characteristics of PTSD, most notably with alcohol dependence.  He goes on to say that, there are not many cases of this disorder without co morbidity of some mental illness along with PTSD. 
Chemical Dependency and Cassandra’s Family
Net Industries (2011) reports that chemical dependency results from a very complicated interface with factors stemming from a variety of areas such as the individual themselves, the neighborhood they live in, society, family, friends, and even genetics.  It is found in studies that chemical dependency is inherent within families.  This is due to both genetics and familial values concerning drugs and alcohol. They also go on to note that sexual abuse in families and relationships that are difficult, also increases the risk factor of substance abuse (Net Industries, 2011). 
Cassandra’s family has a history of several items of importance in this article.  Her father is an alcoholic, and her brother has had problems with heroin addiction, so there are at least two close family members with substance abuse problems.  We know that her father was a violent drunk with a history of sexually and physically abusing her mother and that Cassandra was a witness to this, which is her initial point of trauma.  Cassandra also suspects that her father has done this to her as well, but does not remember.  These are all environmental indicators of risk factors for substance abuse, and should be considered when dealing with Cassandra’s issues, but what about the inherited ones?
Inherited Traits
Agrawal & Dick (2008) have studied twins, and have found that there is a correlation between chemical dependency and shared genetic traits.  These traits also increase the risk to other forms of character traits such as antisocial personality, ADHD, and some forms of conduct disorder.  The reason for this shared trait risk is that these disorders are mainly associated with uninhibited behavior, so they are closely related.  In fact, the estimated rate of inherited risk is in the range of 45%-79%, which is a rather large number.  Another thing to consider is that the inherited risk affects all individuals differently, therefore, while Cassandra’s father was an alcoholic, the inherited risk showed up conclusively in her brother as drug use, and possibly in Cassandra as antisocial personality traits or ADHD (Agrawal & Dick, 2008).
Buxbaum, Flory, Ising, Holsboer, Pratchett & Yehuda (2010) hold that there are also conclusive studies that show that exposure to early life stressors such as Cassandra’s exposure to violence and sexual abuse, can lead to adult onset of PTSD.  They suggest that DNA functioning when exposed to early serious stress in life can be altered by the exposure through epigenetic paths.  They also suggest that the environment can also be contributing factors in permanent changes on the molecular level.  They hold that it is a multitude of factors, including “genetic, epigenetic, neuroendocrine, psychological, and environmental,” that can affect whether or not a person may develop PTSD as an adult (Buxbaum et al, 2010).
Prioritize: Assessment Model and Course of Action Required
The biopsychosocial method of assessment seems to work well for this situation.  When using this model, Hutchinson (2010) suggests that, the information that you would gather from the patient is their identifying information, present psychiatric symptoms, past history of treatment, any mental health medications they may be taking, medical concerns, and any current medications that they may be taking including over the counter medicines like NSAIDS.  We would also get a substance abuse history, family history, particularly where mental illness was recorded and religious views.  This model also covers education, work history, legal history, marital/relationship status, a summary impression, and short-term goals for the client Hutchinson, 2010).
Here is Cassandra’s biopsychosocial assessment:
Eastern State Hospital Crisis Intervention Biopsychosocial Assessment Form
Client: Cassandra Smith            DOB: 8/15/1985     Client CIS ID# CIT10854
Address: 3543 Sunnyvale Lane                           Client SSN: 409-65-8930
City: Lexington   State: KY   Zip: 40517   Phone (859) 849-5298
Identifying Information: Cassandra is a 26 year-old female, presently in custody of the Lexington Police Department who brought her here for assessment of danger to self or others, as she is currently detained for a domestic dispute with the possibility of homicide being investigated.
Present Psychiatric Illness/Symptoms: Client reports that she has nightmares, about her father in which she rolls into a fetal position and sweats profusely when she thinks about him and difficulty sleeping which she has had since she was a child.  She also reports that she often has thoughts of killing a family member to see what it feels like.  Other than this, she appears fidgety, anxious, and is repeatedly asking to see her boyfriend. 
Initial Patient Screening Date: 11/22/2011
 History of Treatment: Client reports that she saw a psychiatrist as a child in Argentina, and that she was treated three times for attempted suicide, the last time being three months ago for cutting her wrists.
Mental Health Medications:  Client reports that she is not currently, nor has she ever been prescribed psychiatric medications.
Medical Concerns:  Client reports that she has no current medical concerns with the exception of having trouble sleeping due to nightmares about her father.
Current Medications: Client reports that she took some Advil earlier to relieve a headache, but that it should have worn off by now.
Date: 11/22/2011
Dependency/Addiction Issues: Client reports that she drinks alcohol regularly, beginning at 15, and occasionally uses marijuana. She also regularly uses caffeine by drinking coffee (4 cups a day approximately).
Family History of Psychiatric Addiction/Illness: Client reports that her father has an addiction to alcohol, and that her brother has had problems with heroin.  She also states that her father has a history of violence when drinking, that her mother was sexually and physically abused by her father and grandfather in Argentina, and that she thinks she may have been as well but cannot remember.
Spirituality: Client states that she believes in God but has no specific religious preferences.
Personal History: Client was born in Argentina, and has one sibling (brother).  Her father was an alcoholic that physically and sexually abused her mother, and the client states that she thinks that they may have abused her too, but cannot remember.  She still speaks to her mother but they are not close, and her father is estranged to her.  They still currently reside in Argentina.  She has not talked to him in ten years since she came to America.  She hated to leave her mother, but was told to leave and go to America to find work and the American Dream.  Client states that she came here to live with her older brother when she was 16, and attended high school.  This was a difficult transition for her, since she spoke no English upon arrival.   She tried to commit suicide within her first year here, but her brother stopped her. 
Education: Client graduated from high school with average grades, and attempted college, but dropped out after two semesters.  Student had low grade point average in college.
Work History: Client currently works in customer service at a busy convenience store.
Legal History: Client is currently in custody of the Lexington Police Department, she is being detained for a domestic disturbance incident, but the police also have some indications that she may have killed her boyfriend.  Prior to this, she has been arrested for public intoxication twice, and had a few traffic tickets.
Marital/Relationship History: Client states that she lives with her boyfriend, and that he gets angry when he is drinking.  She states that they had a fight, and she needs to talk to him to apologize.
Mental Status: Client appears anxious and fidgety, and cannot seem to answer questions directly but is cooperative.  Her mood is worried, but due to circumstance seems normal.  Client’s thought process is logical, but when asked about homicidal ideations, she smiles when talking about killing a family member.  When asked about suicidal ideations she claims to have none currently.  Her speech is smooth, and client seems calm until the officers inform her that she is not free to leave or stop the interview after about a half hour.  She then becomes completely agitated, yelling, cursing, and screaming at the officers.  They have been there the entire time, refusing to leave because she is in their custody.
Summary Impression: Cassandra S. is a young adult suffering from Chronic PTSD with the initial trauma occurring when she was just a child.  She has a strong hereditary link to alcoholism, substance abuse, and violent reactions, possible factors related to relationship problems and memory repression related to the initial trauma from her childhood.
Short Term Goals:       1. Hospitalize for 72-hour observation period in which she is to                   receive a medical evaluation to rule out any medical causes for this issue.  Client will remain in hospital custody until discharged back to the police.  2. Develop safety plan in case suicidal ideations return.  3. Locate brother, to see if he can shed any light on family history.  4. Get Cassandra to sign a release form to obtain information from previous hospitalizations.            

        Figure 2

Getting the Information Needed to Proceed
In this case, all information with the exception of the officers letting the crisis worker know about the suspected homicide has been provided by Cassandra.  We need to verify this information with her brother, friends, and co-workers.  We will also need to locate her previous hospitalization records. To do this we must have the client sign a release form to be able to ask for the records due to confidentiality requirements. 
Useful Characteristics of a Crisis Worker
It is important that we have as much information as we can on her background, because clients sometimes do not remember, or omit information.  A successful crisis worker possesses more than just the knowledge retained out of books.  One helpful characteristic is that the worker has had a plethora of life experiences, allowing them to relate to many situations, notes James (2008).  Since the crisis worker must deal with many cultural backgrounds, it is also effective for the crisis worker to have understanding of the cultures that make up their communities, and possibly to know the main languages of the community for easier communication.  They should also have a great deal of poise and creativity along with flexibility, which will help them, deal with the evolving situations during crises.  Another useful set of characteristics is energy, resiliency, quick mental reflexes, tenacity, courage, optimism, and calmness under duress.  It is these very characteristics that allow them to follow the crisis intervention models, and come up with positive results (James, 2008).   
Seven Stage Crisis Intervention Model
Ottens and Roberts (2005) have come up with an effective seven-stage crisis intervention model.  This model is great for brief treatment situations in a multitude of mental health settings.  The premise is that you first plan and perform a complete biopsychosocial and danger assessment.  The next step is to make a rapid psychological bond with the client and quickly establish a cooperative relationship. After this, we should identify the main issues including the events leading up to the crisis, and then persuade client to explore emotions and feelings.  The last three steps are to form alternative coping skills and alternatives to the crisis, implement an action plan, and plan follow up sessions with the client.
Behavioral Issues, Escalation, and Safety
We have already performed the biopsychosocial assessment of Cassandra; however, it is time to look at her behavioral issues, any chances of escalation, and safety for all involved.  In this case, several things need to be taken into consideration because the client has both homicidal ideations and has attempted suicide on three occasions.  Cassandra is already in the custody of the police, and we are going to hospitalize her for the next 72 hours for observation.  When she is in the custody of the hospital, there will still be officers at her door all of the time.  Because of these facts, Cassandra is probably not in immediate danger of harming herself or anyone else for at least the next 72 hours. 
Particular Issues Cassandra is Experiencing
Cassandra is experiencing trouble sleeping due to nightmares she is having about her father.  For this symptom, we will give her Ambien to help her sleep.  This is the only pharmacology that we will administer, especially due to the inherent risk of substance abuse found in PTSD patients.  With this disorder, lack of sleep or restful sleep is a hallmark, and lack of sleep can produce hallucinations, irritability, and other symptoms of PTSD all by itself.  The National Center for PTSD (2010) recommends that the best psychological treatments that are the most effective in the treatment for PTSD are cognitive behavior therapies these will help Cassandra process the original trauma and develop better coping skills for future issues since PTSD can be cured when the client processes the information correctly.  Specifically psychoeducation, anxiety management, exposure treatments, cognitive restructuring treatments, and Eye Movement Desensitization and reprocessing are the most effective forms of cognitive behavior therapy in the treatment of PTSD, offering the best chance for positive outcomes (National Center for PTSD, (2010). 
Ethical Considerations
According to James (2008) crisis, intervention work comes with certain ethical guidelines and laws that must be followed in order to protect all involved.  The most important of these is that the law does not have jurisdiction to override the patient doctor confidentiality rights that the law affords through HIPPA and FERPA.  The police officers refusing to leave the room is a violation of the client’s rights.  For this reason, among others, we chose to hospitalize Cassandra, and remand the officers to the door of her room.  The only time this is overridden is when the patient is a danger to themselves or others, then, it becomes a moral, ethical, and legal duty to warn.  In this case, since Cassandra is already in police custody, and will be monitored 24 hours a day when hospitalized, there really is not a duty to warn consideration concerning her homicidal ideation and suicide possibilities right now.  
What we have discovered, through the study of Cassandra is that even things that we have forgotten, or do not think about regularly that has happened in our childhood can have lasting effects on a person.  Traumatic events that are stressful can change the way our bodies react to stress and the stresses of life even years later.  Ever since the change from institutionalization to deinstitutionalization, in the mental health care system in the 60’s the mentally ill are being put back in the communities in staggering numbers.  The role of the crisis intervention worker was created to deal with the growing number of mentally ill and the crises that people are ill equipped mentally to handle and they must be equipped and trained to deal with common mental illnesses such as PTSD. 

Agrawal, A., Ph.D., & Dick, D.M., Ph.D., (2008).  The Genetics of Alcohol and Other Drug Dependence.  Retrieved From: http://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf
Barlow, Durand, (2007).  Essentials of Abnormal Psychology.  Mason, Ohio.  Cengage Learning
Buxbaum, J. Flory, J.D., Ising, M., Holsboer, F. Pratchett, L.C., & Yehuda, R (2010).  Putative biological mechanisms for the association between early life adversity and the subsequent
            development of PTSD.  Retrieved From: http://www.springerlink.com/content/y1648j02px843n08/fulltext.pdf
Hutchinson, L., Ph.D., (2010).  24-Biopsychosocial assessment model example.  Retrieved From: http://networkedblogs.com/bcLNn
James, R.K. (2008).  Crisis Intervention Strategies, Sixth Edition.  Cengage Learning.  United States
Net Industries (2011).  Substance Abuse: Family Factors Contributing to Risk and Resiliency.  Retrieved From: http://family.jrank.org/pages/1648/Substance-Abuse-Family-Factors-Contributing-Risk-Resiliency.html
Ottens, A.J., Ph.D., and Roberts A. R., Ph.D., (2005).  The Seven-Stage Crisis Intervention Model: A Road Map to Goal Attainment, Problem Solving, and Crisis Resolution.  Retrieved From: http://homepages.stmartin.edu/fac_staff/staylor/Semesters/Fall%202008/Interviewing%20Fall%202008/7%20Stage%20Crisis%20Intervention%20Model%20A.pdf
SAMHSA (2009).  Office of Applied Studies: Results from the 2008 National Survey on Drug Use and Health: National Findings, Figure 8.1.  Retrieved From: http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#Fig8-1
The National Center for PTSD, (2010).  DSM-IV-TR Criteria for PTSD.  Retrieved From: http://www.ptsd.va.gov/professional/pages/dsm-iv-tr-ptsd.asp
The National Center for PTSD, (2010).  Overview of PTSD Treatments.  Retrieved From: http://www.ptsd.va.gov/professional/pages/overview-treatment-research.asp
The National Center for PTSD, (2009).  Report of (VA) Consensus Conference: Practice Recommendations for Treatment of Veterans with Comorbid Substance Abuse and PTSD.  Retrieved From: http://www.ptsd.va.gov/professional/pages/handouts-pdf/SUD_PTSD_Practice_Recommend.pdf

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